pharmacists' patient care process Flashcards
Subjective information to collect
chief complaint
past medical history
history of present illness
allergies
social and family history
lifestyle/habits
health and functional goals
preferences and beliefs
socioeconomic factors that impact care
Chief complaint
statement of why patient has presented
record in patient’s own words
ask “what brings you in today”
Past medical history (PMH)
past/active diagnoses
hospitalizations
surgeries
accidents or injuries
History of present illness (HPI)
SCHOLAR
symptoms
characteristics
history
onset
location
aggravating factors
remitting factors
Medication history and allergies
current medication list as patient states it (name, dosage, schedule, route, duration, indication, outcome, etc
allergies as the patient states it
Medication experience
general attitude towards taking the medication
patient wants/expectations from drug therapy
concerns about drug therapy
understanding of medication
cultural, religious, or ethical issues influencing willingness to take medications
medication-taking behavior
Social and family history
social- alcohol, caffeine, illicit drug use, nicotine, tobacco
family- conditions in first degree relatives, causes of death
Objective information to correct
vitals
labs/diagnostic tests
physical exam findings
current medications (per chart)
refill records
immunization records
history documented in medical record
drug information
What patient-specific factors should be considered when individualizing the plan?
age, co-morbidities, concurrent medications, risk vs benefit, medication taking behavior, ability to adhere, acute changes in functional status
Reasons for early follow up
past treatment failures
past adverse effects
worsening clinical status
lack of full capability to engage in plan
high risk medications (and not at goal)
Activities during follow-up
evaluate efficacy
evaluate safety
evaluate adherence
identify new DTPs
revise plan
schedule next follow-up
